Pulmonary Oedema incident

[InTheDrink]

Hi, have just posted on RBW an incident I had last month. It was pretty serious and worth being aware of IPE and pulmonary oedema in general.

http://www.rebreatherworld.com/dcs-or-medical-related-accidents-incidents/39754-pulmonary-oedema-incident.html

Best,
John

p.s. full post below over a couple of posts as I am seriously verbose

Back from the brink, Insha’allah

July 2011.
I was doing my rEvo Mod1 cross-over course in Hurghada with instructor Simon Taylor-Watson. I had my two buddies, Tony and Rachel with me, also doing their cross-over. Simon had kindly let us stay with him in his not exactly modest palace house

. Henrik was also staying at Simon’s house, having just completed his cross-over. The first couple of days passed uneventfully and the units, predictably, were a joy to dive.

On the second day of the course on the first dive, Rachel and I spent too long on our bubble and bail check and were blown off the reef with a moderate/strong current. We then had to work hard to try to get back to where we started never mind the actual reef.

After ~20 minutes of this infernal finning and glancing at Rachel with my WTF expression, I finally signaled to Simon I wasn’t great. I was breathing really hard. I was concerned I could be getting a CO2 hit, and from myself rather than breakthrough. We got down on the floor and I dil flushed several times. I still wasn’t happy and indicated to thumb the dive (first time I’ve ever done this). Simon accompanied me (i.e. adopted rescue posture) to the surface and helped manage my ascent. We hung on the 6m line for our stop and then ascended. I got back on the boat and Simon dropped back down and completed remainder of dive with the others.

On the boat, it took me 10 to 15 minutes to get my breathing even close to normal. I made a mental note that two things occurred before I started getting concerned about over exertion. It was preceded by wheezing and I had felt cold during the dive (I pretty much never feel cold and given the work rate, it seemed quite unusual to me - enough for me to note it and mention it to S, T & R).

I was a little shaken by this event but nothing drastic and was happy to get in the water again after lunch. We spent most of the dive at 20m but went to a small police boat wreck about 35m for a few minutes, this after Simon making thoroughly sure I was comfortable and happy. The dive was uneventful and whilst I was a little apprehensive at the start of the dive, from 5 minutes in I was relaxed and happy.

On the next day of the course the first dive was to be to 40m with a number of drills and skills. We dropped down to 6m and did our bubble, bail and cell check. All fine. Did 12m OC swim to measure our RMV. Dropped down to 20m where we did solenoid stuck on/feathered valve O2 drills. This took me a couple of goes to get right as the O2 valve on my tank required a lot of turns to become either off or on. We then dropped down to 40m and did some simulated H and boom drills. I did have a slightly hard time the couple of times I’d tried to just use the ADV on descent, having to take some pretty serious sucks to get enough gas. I went back to manual add after this.

In or around the 40m I noticed I was wheezing. The same wheezing I’d had on the dive the previous day that I had to bailout from. I didn't really think too much about it just wondered why as I've never wheezed when diving (OC or CCR) before.

A few minutes later it happened. 43 mins or so into the dive with a time to surface of 7 mins. I felt a definite tingling around my lips. I checked myself to make sure I wasn’t imagining things. I wasn’t. Checked PO2 – 1.17, on a 1.2 setpoint: fine. I got Tony’s attention to indicate possible issue. Suddenly my head swam and I knew something very bad was happening. I think I thought I was going to pass out. I don’t have any really specific memory apart from ‘something is really really bad and I don’t know what it is – I remember thinking that it didn’t obviously or immediately fit any of the Hs, I just knew it was very bad. Bailed to OC. Simon was with me by now. I (think I) indicated bail to surface immediately. He came with me. Apparently Tony did too at the start before being called back by Henrik (good call) but I have no decent recollection of the next couple of minutes. I blew all our stops. We took about 2.5 mins to surface which was a fairly controlled 14m per minute although a fairly provocative profile. I don’t really remember the ascent to be honest, apart from at some point I wasn’t sure I was going to make it to the surface and the rate we went was definitely the slowest possible. I think I realised my problem was I could not breath but I’m not sure really. I also think, but am not sure, that Simon fully managed my ascent. I think I was just focussing on holding on/staying conscious but again, I’m not sure. I also wasn't sure I'd make the surface so hit the up button around 6 or 8m.

Simon further inflated me on the surface. At this point I was very aware of what my problem was. I could not breathe. ****. I told Simon. He clearly understood the seriousness of the situation and assisted immediately (he thought I’d had a heart attack). He ripped open the front of my wetsuit and ditched my unit. He shouted for help but struggled to get attention for 1 maybe 2 minutes (I could be wrong here, maybe 10, 20 seconds) while towing me towards the boat. I didn’t think I was going to make it to the boat conscious. I was scared and dumbfounded. I knew I was in a bad place.

Apparently the captain and Said (working on the boat) came in the water and pulled me out. Most of the rest I don't really remember properly, apart from like in a dream. It sounds silly but it actually was like some ethereal battle between life and death. I can’t find correct words for how it felt no matter how hard I dig but below is some approximation.

In my dream I was dying. Breathing was getting harder and harder til I could get no breath. Thought oh ****, I will be first rEvo death. Thought oh **** my family. Tried to keep breathing but it was slipping away. I could feel the life leaving me. This is it. ****. Kept on trying to breathe even tho it was so hard and I was getting nothing. I couldn’t breathe. I thought I really cannot do this anymore. It is too hard, it is too tiring. I thought I’d try just one more and then just let it go. And then I don’t remember much of the next while.

From the other people on the boat’s perspectives I was also not in a good place. I was apparently drifting between conscious/unconscious was grey/blue in colour and mostly unresponsive. Apparently I was contorting/spasming from time to time. Someone suggested to Tony that he call my wife to advise that I’d had an accident. He declined until he knew which way it was going to go. This stage lasted for about an hour I’m told.

Then slowly I started getting better. I remember being able to move single finger in response to a question (which my buddy puts down to Said (who was tending to me) having the idea to blow thru the continuous flow O2 mask). Prior to that a nurse that happened to be on boat tried to get me on a drip but the kit was unfamiliar to her apparently and it just ended up with blood on the deck. None of this I remember although I do remember some voices for some parts of it. I was on continuous flow O2 all the time.

My recovery continued. Each time I improved a little bit more I was able to cough up some more gunk which created a bit more space in my lungs for the O2 to reach and so on. At this point I was out of the woods. A further hour later I had even started talking again and was able to walk, assisted, to the stretcher at dock.

5 hours observation and no heart or lung problem (apart from some fluid in lungs) showing in x-rays or ECGs. Simon, Henrik, Nico, Tony, Rachel and Said were around in the hospital for much of the time and it felt good to have them around. I was even amused when Said (presumably when asked by the doctor about my body colour during the incident) scanned the ward looking for an appropriate reference and finally found something he felt was the right colour – and vigorously tugged his light blue t-shirt. The doctors at the hospital were very nice (if perhaps somewhat preoccupied with guaranteed payment for the ensuing chamber rides – thanks Tony for giving them your credit card before DAN waded in). Did a 5.5hr stint in the chamber then two further 2 hour sessions the following day. I do not think I was bent, but I guess they were taking precautions (although the formal medical diagnosis is DCS Type II – which I do not accept as the primary issue that I had). I was discharged the following evening of the second day as I didn’t feel the chamber rides were doing anything for me.

Now I'm trying to work out wtf happened to me on this dive. I don’t think I panicked (but I'm aware it could look like that). I just knew there was a problem that couldn't be fixed underwater and indeed it very nearly was not fixed on the boat. I discussed this with Simon afterwards and whether I should have tried to fix the issue underwater first but he was of the same opinion – I wouldn’t be here typing up this report had I hesitated. As it was I couldn’t make the last few metres without the up button – I had no more time to be underwater. Plenty of people will want to slate me for this no doubt. I pray that such wise voices are never placed in the same position as I was. So please, if your normally calm buddy one day displays some signs of panic – don’t automatically assume that’s what it is. If your buddy has a significant medical event underwater then some signs may seem similar but be slow to judge and be quick to assist. Like Simon did for me.

I cannot thank enough the people that pulled me through this incident. Simon risked his own skin blowing his stops from 38m in order to get me up there. He had to go back in after getting me back on the boat and do his missed stops and then get on O2. He said when he got back on the boat he didn’t expect to be seeing me again. I don’t think anyone did that saw my condition in the first hour or so, myself included. But my wholehearted thanks to Simon for saving my life.

The boat crew and the divers on the boat were also amazing. Said took charge of the scene and whilst it was a group effort with him, other boat crew and other divers that had medical training, I believe that it was Said’s efforts to apply positive O2 is what brought me back. I couldn’t breathe for myself so someone else needed to push the gas in there.

As to what happened to me and why? I’m looking for answers. Digging round on the internet and speaking to some people who have had IPE (immersion pulmonary oedema), a lot of the symptoms sound very similar and the unfolding of events and not being able to breathe were very closely matched, although apparently I did not have red frothy sputum coming out of my mouth (though as I was recovering each time I was able to cough up more gunk I got a little bit more room to get gas in my lungs and so on until by the time I reached the dock 1.50 after the incident I was 95% better.

It’s worth mentioning that the rescue boat they sent for me went to the wrong location. Yeah, awesome work guys. By the time they managed to catch us up we were nearly at port and our crew (thankfully) declined their offer of assistance as it would have simply delayed things. It is worth remembering that rescue services in poorer areas of the world might not be as efficient/competent as the UK. As it happens I am very glad that I remained under the care of Said and the others and ultimately glad the rescue boat screwed up and went to the wrong place. I’m not convinced that they would have provided the level of care I received from my boat. The boat is part of Dive Connection’s operation and I would strongly recommend these people to anyone. They are top drawer and lovely people too. And they even have beer. If Carlsberg made Dive Ops….

At the hospital they did ecgs, x-rays, bloods, etc. They found some fluid in my lungs but it really must have been the dregs. If anyone has any ideas on anything else it might be then I’d be keen to hear. My symptoms don’t seem to match the chokes and my problems started happening before ascent.

At this point I really don’t know what happened to me and what caused it. I do know that until I find out these answers or some kinds of assurances I won’t be going back to CCR, any deep dives and I need to consider diving altogether. I cannot risk putting my family or fellow divers at risk of the fallout of another event like this. Maybe this is me done with diving for life. That would be a blow as it is a huge part of my life.

The Thursday following the incident I got the chance to go see the crew from the boat to thank them personally. They all seemed overjoyed to see me. It was a good experience. I was able to speak to Said personally who really did an amazing job of keeping me alive. He is a lovely bloke and I’m very glad he was on the boat that day. I was on the way out and whatever he did (Tony thought it was the application of positive pressure on the O2 mask) somehow got me back from the brink after pretty much everyone thought I was done for. The team caring for me did a brilliant job and I’m here thanks to them and to Simon for getting me to the surface without consideration for his own well being. Words will never be enough to express my gratitude.

After seeing the crew we went back to Nico’s shop (Dive Connection) and most of the guests that had been on the boat were there. Again, more applause. I raised my fists in defiance – I’m still here! - but my lip was wobbling. Talking to some of the guests it became apparent that this incident impacted everyone, not just me, my buddies, Simon or the people immediately tending to me. But the happiness, genuine happiness on people’s faces to see me again, and walking, talking and swigging a beer – was lovely. One of the Egyptian crew said to me ‘now I don’t need to say goodbye to your wife’ (apparently even when dying I don’t lose my capacity for melodrama and made this request to both him and Rachel

)

 

[InTheDrink]

Postscript
I’ve been really fortunate to have been in dialogue with a couple of amazing dive doctors that took an interest in my incident. They have kindly reviewed my x-rays, reports and other medical records from the incident. Both agreed that pulmonary oedema and likely immersion pulmonary oedema (IPE) is what nearly definitely occurred.

I have subsequently been to the London Hyperbaric Chamber and the doctor has also diagnosed Pulmonary Oedema. Fluid in my lungs is clearly apparent in the x-rays despite being a few hours after my incident and when I was well into the recovery phase.

We’re embarking on the journey to find out what caused the IPE. Initial blood pressure tests indicate that I am borderline hypertensive. Hypertension appears to be a risk factor for IPE. Whilst it is not clear yet whether hypertension or any other things played a role in my incident, I would nonetheless suggest that if you have high blood pressure, discuss it with a dive doctor. There are dive-suitable anti-hypertension meds apparently. I’ll post more on this if and when I learn more. At this stage I really don’t know much about any of this so take it for what it’s worth. I’m seeing a cardiologist next week too so I’ll post any answers I get to this thread.

I thought there were some obvious lessons to be learned from my incident and I still believe this may be true, but currently it does seem like this kind of event can happen to anyone. Please people, be aware. Maybe develop some signal for ‘oh ****, stuff has turned seriously weird, I need to get the **** out of here pronto, no discussion’. If I had tried to communicate with my buddies what the problem was I would be dead. I simply did not have enough time. The three Hs are indeed to be reckoned with – but not to the exclusion of all else. They are not the only things that can happen on a rebreather. I know that I am a novice and preaching to people with infinitely more experience than I – but just in case; remember that not all problems are Hs and not all problems can be solved underwater. You might disagree with the latter part of this sentence and indeed, so would I 6 weeks ago.

Simon TW could so easily have decided I was just being a muppet and insisted I dealt with the problem underwater. The man is insightful enough to understand that not all problems can be solved underwater and somehow had the grace and understanding to acknowledge my decision but also to come with me all the way to the surface. Without his actions – both trusting my judgement, accompanying me to the surface and risking DCS himself - I would not be here today.

This wasn’t a rebreather accident – the rebreather was operating fine. But I want people to know that seriously bad stuff can happen that isn’t in the book. You should at least be aware of IPE, the signs and symptoms and remedial measures should you or your buddy ever have the misfortune to get it.

I’ve also included my buddy’s report below to give another perspective. Apologies for such a long post. Brevity has never been my forté.

Dive safe,

John

*****

Tony's incident report – 12th July 2011 written 16th July

Pre dive checks all ok, bubble and bail at 6m, no problems identified, went to 12m, all bailed out and swam for 5 minutes on stages for RMV check. Shearwaters left on CC during drill. Then we went back on the loop and carried out a solenoid stuck open drill, manually opening and closing the oxygen cylinder to control ppO2. Simon took a long time explaining to John what drill we were supposed to be performing and how. During this time I wasn't really watching them I was just concentrating on controlling my own ppO2. We swam along performing the drill, then reverted to normal operation. We descended to approx 40m and were swimming along the reef, with Simon turning from time to time to ask us to carry out 'H' or 'Boom' drills.

We were approximately 40 minutes into the dive, with a TTS of around 7min, when John tapped me. I wasn't sure if he was trying to attract my attention or merely indicating he was there to avoid collision, as when I turned his stage was close to my head. As I turned to him he bailed out onto open circuit, and Simon swam over, offering John his stage reg. John started to ascend and initially both I and Simon went with him, Simon in front, and me holding I think his leg, to prevent a sudden uncontrolled ascent. At this stage I had no idea what the problem was. After we had ascended a few metres, Henrik shouted for me to remain at depth, so I returned to him and Rachel, and Simon went with John to the surface.

Me, Rachel and Henrik ascended slowly whilst swimming back to the boat, and on arrival completed 9m, 6m and 3m stops, then climbed onto the boat. Simon was by then back in the water, decompressing. John was lying on the deck, out of his unit and wetsuit, with his legs elevated and his attendees were wrapping him in foil. He was breathing oxygen through a continuous flow mask. His eyes were closed, he was grey and appeared unconscious, but was moving his arms and torso in what appeared an uncontrolled manner. About 20 minutes had passed between John surfacing and me arriving on the boat.

I removed my unit and wetsuit, and went to kneel by John's head, and spoke to him, explaining that he was back on the boat, and being looked after and that emergency services had been alerted. He showed no signs that he could hear me. He was being attended to by Sayed one of the dive crew, and a guest who appeared to be a nurse, whilst another guest was holding his legs elevated, and I think massaging them, I'm not sure. The nurse tried to intubate first his right arm then his left, without success, merely spreading blood over the deck. She gave up and put a plaster on the vein and held the arm bent to stem the flow.

Sayed took a pulse, which he described as 7 beats then nothing, 7 beats then nothing. He was asking John questions, is there pain, can he move various parts of his body, and it did appear that John was nodding and shaking his head in response to these questions, though only weakly. He was struggling to breathe, and continued to move his torso and arms, I believe in an attempt to breathe.

Sayed and then the nurse used a stethoscope to listen to his chest, neither seemed really sure but they reported it sounded like there was liquid in the lungs especially the left side. They tried to induce John to drink from the saline solution but without success, pouring a small amount into his mouth which just dribbled out again.

Sayed changed the mask to a pocket mask, and blew into it to force oxygen into John's lungs, twice I think, and this appeared to have a dramatic effect, John's eyes opened and he appeared more responsive. He changed the mask back to the previous one, which I think he felt made a better seal. From this point on John's condition improved, his responses became more definite, nodding and shaking his head, and trying to remove the towel and foil. He was sweating, his forehead was wiped a few times, but he appeared to be feeling too hot. He tried again to drink from the saline, and was able I think to take a tiny amount in before indicating he wanted to go back onto oxygen. Once he was able to speak weakly, he complained that he was unable to breathe.

He became more and more responsive and by the time we were approaching the marina, possible an hour and a half or 2 hours from the incident, he was able to sit up and drink, though only briefly before wanting to lie down again, and still struggling to breathe. The oxygen cylinder was exhausted and the crew swapped it for a demand valve. John had difficulty breathing from this, and had to push the purge button with each breath. It became impossible to breathe from once there was 50 bar left on the gauge.

As we arrived into harbour, John sat up and was helped onto the bench. He said to me that as soon as possible he would like to go back on to oxygen. The medical staff came on board, consulted briefly with the crew, and then walked John, supported each side, off the boat, and onto a stretcher, and into the ambulance.

 

[Cave Diver]

Thanks for posting. It seems that more of these cases are coming to light. I think that many diving incidents that get classified as drowning or heart attacks could very well be a result of something like this that just isn't being caught.

 

[CheddarChick]

Wow!!!!!!!!!!!!!!!!!
So glad you are ok.........Please get the best treatment/advice and follow it!!!!!!!

 

[InTheDrink]

Thanks for posting. It seems that more of these cases are coming to light. I think that many diving incidents that get classified as drowning or heart attacks could very well be a result of something like this that just isn't being caught.

Cheers John,

It does gall me now thinking how many fatalities might have looked like they freaked and were labelled 'panicked diver' but were not. It seems a disservice to their memory. If it wasn't for my instructor I know I would have had such a label. Can't imagine it would make my wife's grieving any easier.

I hope people realise that this is something that whilst rare, is not to be ignored.

John

 

[Ayisha]

Insha'Allah indeed. Wow, what an experience. It does seem that you are very lucky to be alive and very lucky to get exactly the help you needed exactly when you needed it. Kudos to all the skilled help around you.

I also think that there are more cases of IPE than we hear about...

 

[Bubbletrubble]

FYI, Denisegg shared her IPE incident here on Scubaboard. She was under the care of a "physician" who was treating her with thyroid medication unnecessarily. Thyroid hormone affects lots of different physiological processes in the body, one of which is blood pressure. In fact, I wouldn't be surprised if a link were found between elevated levels of thyroid hormone and pulmonary hypertension.

Experts still don't know what factors cause IPE. Perhaps with more research we'll have a better handle on how to prevent it.

In the meantime, it would make sense to have comprehensive bloodwork performed (sounds like that's already been done), get your respiratory and cardiovascular systems thoroughly checked out (pulmonary function tests, stress test, etc.), and ensure that your blood pressure is in the normal range. Treatment of hypertension can include any combination of the following: lifestyle changes, dietary modifications, increase in physical fitness activities, meditation/hypnosis, and oral meds.

 

[TSandM]

I think that many diving incidents that get classified as drowning or heart attacks could very well be a result of something like this that just isn't being caught.

This has troubled me with respect to the "unexplained" deaths, from the time I first read about the condition. It is my very great fear that drowning and IPE look enough alike on post-mortem for one to be mistaken for the other.

I wonder about WOB on rebreathers -- I know it's higher than on OC, but by how much? You can induce pulmonary edema in normal people, if you make them pull hard enough to breathe for a long enough period of time. I wonder if this is a factor in CCR IPE cases?

 

[Cave Diver]

I wonder about WOB on rebreathers -- I know it's higher than on OC, but by how much? You can induce pulmonary edema in normal people, if you make them pull hard enough to breathe for a long enough period of time. I wonder if this is a factor in CCR IPE cases?

Might be a good question for DDM. I think he's been taking part in doing a study on this condition. I'm sure he'll be along shortly.

 

[Bubbletrubble]

@InTheDrink: Just a few questions...

• Were you taking any prescription medication(s) at the time of the incident? In particular, were you taking any heart or blood pressure meds?
• Were you taking any anti-seasickness medication at the time? If so, what type and how much? Also, was the dosage on the day of the incident a departure from your regular routine, i.e., took more of the med than on a typical boat dive?
• Is it possible that you were over-hydrated? More specifically, describe your pre-dive fluid intake. Some divers tend to be rather aggressive with drinking fluids prior to a dive due to the notion that dehydration might increase the probability of DCS occurrence.